Lipoprotein(a): Actionable today, treatable tomorrow?

BACKGROUND: Lipoprotein(a) (Lp(a)) is an atherogenic, low-density lipoprotein (LDL)-like particle whose concentrations, mostly genetically determined, are elevated in about 20% of individuals. It is a major and under-recognised independent risk factor for atherosclerotic cardiovascular disease (ASCVD) and aortic valve stenosis. OBJECTIVE: To review current evidence, international recommendations and future directions around testing and management of elevated Lp(a). DISCUSSION: Among other high-risk groups, measuring Lp(a) is recommended in people with ASCVD or aortic valve stenosis, especially if they are of young-onset, familial, unusually severe or progressive. Indeed, some international guidelines advocate measuring Lp(a) in all adults as part of cardiovascular risk assessment. While specific Lp(a)-lowering therapies are not yet available, risk-reducing measures for people with raised Lp(a) include addressing absolute ASCVD risk by diet and lifestyle measures, along with pharmacological LDL-cholesterol reduction. Aspirin might also have a role in primary prevention. Lp(a)-lowering therapies that act by preventing its formation are the subjects of ongoing clinical trials focused on cardiovascular outcomes, the first of which is expected to report in late 2026.